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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS oWNER B('I,DER DEI,CARATION
<br />I h.Bh, rrfirn lndcr lenally oi perjury rhar I {n cxcnDr rrorn thc Gn rado6' Liensc trw for lhc iollo*ins rcuur (Sc.7o:lr 5
<br />Dnsircss rrd Profcsr n Codc) Atry Ciry or C.rir, *hich rcquir.\ a Fhrir h $nd cr. ,li.r. i.rtrov.. d.molish or rclrir any
<br />(ruclurc. prior ro ns nsi.tr.., dh rcquncsrh. rlpli.,trr ntr surh p.nnir ro filc, signcd s,lc f,nr rhar h..r shc is licctrscd |uisu.nr
<br />h rhc lrn,vhion\ oI lhc Conrracnn \ !-iccnscd ljw (Chtrrr$ 9. CoNrcNing wirh Sslion ,lxll ol Dilhion 3 oi lhc Bus.lrc$ lnd
<br />PtuIcsn,i\ Codc)or rh!! hcorsh. n cxcmrr rhclclrom and rh.n sh for rhc alhscd cxcmprion. AnyviolarionofS.crion?0.ll5byany
<br />.t'tlicr ld, [:iinir rubjc.kihr rrpli.a.l h acirilpenllry.tnor mre rhrn lile hundreddo]la6 i55m)
<br />L as osn.r of dL rnliny. or tt c tol.yE\ wirn *!8cs ar rhcir slc comDr nurion. s ill do rnc *or[ rd rhc ddLN n ft
<br />intcndcn or oficrcd tor *& (Sd.?(,l4, Busiftrs nid ft(,fcs\i.n\ ci'dc: thc Gn rnckr's Li.cn\c Iiw ln).s n.r apply h .tr oqkr ol
<br />rhc pmpcny wh) huills or iDlrows rhc@r lnd qho dc su.h *1)* hnnstlfor hctrclfor rhmu8h his or her oEn cnlnLlccs.
<br />lruvidcJ rhrr ru.h impmvcmn*m n iir.aial oroflcr.d lor \ah ll hoN.w, rhc hoilding or iqrmletunr i\ nrld *irhin um )t1tr
<br />or.onphri{nr. rnc Owrcr Euildc, will hnt lh. hurdcn of fmv ! rlrr tEorshc dil ml lDinor inlmr lhc pmpcny for rhc ruF){ ol
<br />l. 3s o*mr .f lhc Dtr,rEny. rm cxclu\ivcly conr,cr ir8 wirh ticcnscd comacror to construd rhc rmj.{l (Se 7(44. Busincs\
<br />aftl Br{ssrnCodc:I'hcConkNror'sLi.ctrs.La*dmsnorapllykrano"nrr.flronntwhobuildrorimlrovcsrhcr.on.
<br />,nd who.a,nrErsaor\rchpojccliwirhrConrrlcto(rltc.scdpusunrr.rhcConrra.roisl-tenrlj*).
<br />Id rcrc rtr u"dcr sc.rnni .B &Pc rbrrhisrcxvrn
<br />uaatrEf,s.t0M.8[Ntar]a!
<br />DEgIISAIION
<br />I hclcby !fi nnlndcr F,rhyof pcrjuryoncof lhc rolh{ing d.clu,rk,.s:
<br />Ihav.n'xlqill'n,i'nrinaCcnilicrirofConscnrhSclfln\urct(r$orksicompcn\!rn,n.rspmvidcdturi,yScciionlTmofrhc
<br />titx, (idc, f{, rhc rErforft$cc olrhc *ork tor which thc pLrnrit n nsucd.
<br />lhrvrrr,ls'llnlrnainsorkdi.otrpcn\inn,in\urrmc.r\rcrluircdhySrcri{,nlTmofrhclxhorG)dr.nnihcpcrlnnrr{or
<br />rhc *ork tur*hrhrhi\ fi,rn i\ issucd My$orkcrr co Fnrari,n, nNUrnRrcxd.r md F,licy nun$.r rc
<br />Policy Numb.n_Ernnes:
<br />-lucniiyrlrrrillhcpcrfonnrftcoIrh.sorkntrshi.hIhi\Fnniri\i\\ucd.I\hrlliorc'ntlot
<br />nyNr* irrtrynmncr
<br />v' * n, l*dnn. sl,jc.l lo I hc workcr( (ortEn\lritr h$ or C{libfliia. ud arrc hnr il I should hco'm su6icci h ih.
<br />work.^ .o,pciuri{nrpovisi,,tr\ors.criu.l?O0otlhcl-ahor(i!lc.lshrll,lnnIwilhcomnlrNiihihoscptr)vi\i,nr
<br />WARNINC: Frilurc t() sccurc rntcs
<br />cieil 6trc\ up to onc hundicd lhousond
<br />:-,'"'ffY'y-
<br />contctrsritrri rovcfulc r\ u rh$hrl. nDd
<br />loll{c (SltD-000). ir diriotr Ir' rlr oi.omlEDsatiotr- drnmBc
<br />t)ll t. (R \ (,\
<br />I hcdht rfilr r n rr Ffrhy of ncrjry rhd I trm licnsL\l undcr tnovhion oi Chlplcr I (connm,rin8 s irh Srcrin TOrD) or Diriskn .l
<br />ol rhc Bu\iM$onn Prot $ionsCodc. and rr li.cnsc h h hllror.c iM cr'iar
<br />{ ,^"*",K
<br />r0lsltsll-I]0lllill2lNli:llj
<br />I hcchy sfln unlcr ltnllrr of pcrju,y lnll rh.rc t a connrudion lcndin8 uency for rhc Frtomncc of lhe work tur qhih rhis Fr ir i!
<br />niucd (Scc.1097. Civ C.)
<br />ATTIICANLDECLAAAIII)N
<br />I hs.+yatrmlnder pcnahy of lcrjuryorc of ltc followin8 d(hEtions:
<br />Dcmlnhn PcrmirrAsiE{os Nolification F.dc6lRcSDl io.s(Tnh 40. Pan6l
<br />-Rcquncd
<br />Lettcr ol Noli,lcoliotr
<br />-l
<br />lanifylh{ rhr fcdcral re8ulation! Esa!"lin8 lsbcstosr.trDv arc rcr lpnlicablc lo this prcicr
<br />I cdilyrhd I hr\c rc d lhir.ppli.di,,n (klsd.rhnr rhcrtl)vc ink n i\conccr I agrl! h c.nlPly wirh rllCiryrnd C.utrry
<br />orlinumcsn Shc tjws rchrine to hu ildin8 consndmn. xlhc
<br />{hovc
<br />'mnh.ncd !tup.rly tu iNnr.rionN{x)
<br />bo-,
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Lighl Standards
<br />as, Pool, Fountains
<br />Signs (monument)
<br />!!!9 Safety /Low Voltage
<br />Fire Alarm i Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundino i UFER
<br />Translormers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Solfit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />[/]eter Release
<br />Ro ugh
<br />Service lvleter
<br />FINAL 1/za/t<t s\<t
<br />Notes, Remarks, Etc.
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